Ingestion of foreign bodies among prisoners: a ten years retrospective study at University Hospital of Southern Italy.

INTRODUCTION: We studied 21 episodes of ingestion of foreign bodies (IFO) among 15 prisoners. PATIENTS AND METHODS: Rectrospective research in pts admitted to emergency from June 2005 to May 2105. Ingestion, management and pts outcome were analyzed. Prisoners with previous esophagogastroduodenal disease were excluded. RESULTS: All pts were males and ingestions were intentional. Esophagogastroduoduenoscopy (EGDS) was performed in 10pts (8 cases with successful removal, 1 case we did not find anything e 1 of unsuccessful EGDS, that required emergency surgey. 9 pts rejected EGDS: in 2 pts were not necessary.Among the 9 pts that rejected EGDS, 5 discharged voluntary. No mortality neither morbidity. Only 1 pt required surgery.The IFO were 34 (23 sharp, 6 flat,5 indefined). We did not observe any food bolus impaction. Multiple ingestion was found in 11 pts. Recurrent episodes were found in 4 pts. DISCUSSION: Almost all episodes can be treated conservatively with observation and endoscopy but the management of this pts has a financial impact on healthcare cost and on security costs. Prevention strategies are important to predict patient group at high risk for recurrent IFO.

Systemic air embolism as a complication of percutaneous computed tomography guided transthoracic lung biopsy.

A 57-year-old man underwent prone position computed tomography (CT) guided percutaneous transthoracic lung biopsy. After removal of the 18-gauge biopsy needle, the patient lost consciousness and developed shock. CT showed signs of air embolism in descending aorta and left atrium. Cardiopulmonary resuscitation was unsuccessful. A postmortem CT scan confirmed a massive air embolism in the descending aorta, left ventricle and brain. Systemic air embolism occurs in around 0.001-0.003% of lung biopsy procedures. Recommendations to reduce the risk include requesting the patient to stop breathing during the procedure and preventing the exposure of the outer cannula of a coaxial biopsy needle to the atmosphere.

Long lasting postoperative ileus after surgery for intestinal obstruction due to left paraduodenal hernia (LPDH). Case report.

Left paraduodenal hernia is a rare congenital anomaly which arises from an error of rotation of the midgut; sometimes can be responsible for intestinal occlusion, that require surgery. In many cases of literature a prompt diagnosis and therapy reduced morbidity and mortality and almost all patients were discharged on 4th or 5th postoperative day (POD). We report a case of a 59 years old patient who underwent surgery for intestinal obstruction due to a massive left paraduodeneal hernia, that had a very long period (20 days) of postoperative ileus.

THORACIC INVOLVEMENT IN CONNECTIVE TISSUE DISEASES: RADIOLOGICAL PATTERNS AND FOLLOW-UP.

Connective tissue diseases (CTDs) are a heterogeneous group of idiopathic inflammatory diseases involving various organs. A thoracic involvement is frequent, and chest-CT represents the imaging technique of reference in its assessment. Pulmonary abnormalities related to CTDs are various; although several disease-specific aspects have been described, the two most clinically relevant complications are represented by interstitial lung disease and pulmonary arterial hypertension. The early identification of a thoracic involvement, with the adoption of specific therapies, can significantly change patient's prognosis. The aim of this article is to review the most common typical and atypical CT features of thoracic involvement occurring in CT, especially focusing on interstitial lung disease.

Unusual liver abscess secondary to ingested foreign body: laparoscopic management.

Liver abscess is a cause of febrile abdominal pain and usually the origin of a liver abscess is ascending cholangitis, hemathological diffusion, via the portal vein or the hepatic artery, or superinfection of necrotic tissue. Solitary pyogenic abscess with no obvious systemic cause may be secondary to a local event such as the migration of an ingested foreign body. We report the case of a solitary liver abscess caused by an ingested foreign body, a fish bone, migrated through the gastric wall into the left lobe.

A combined therapeutic approach in progressive idiopathic pulmonary fibrosis-pirfenidone as bridge therapy for ex vivo lung transplantation: a case report.

Idiopathic pulmonary fibrosis (IPF) is a progressive fibrosing interstitial pneumonia of unknown etiology, which is associated with the histopathologic pattern of usual interstitial pneumonia (UIP) and leads to a progressive decrease of respiratory function. The present article describes a case of a 62-year-old ex-smoker referred to our hospital because of IPF. After 2 years of follow-up, the subject experienced a significant worsening of pulmonary function and was enrolled in a lung transplantation program. Afterward, a pharmacological treatment with pirfenidone was started, achieving a stabilization of respiratory function. The patient underwent a single lung transplantation by means of a normothermic ex vivo lung perfusion (EVLP) approach according to the Toronto model. At 20-month evaluation the subject's respiratory function was significantly improved, and quality of life was considerably ameliorated. We believe that an integrated multidisciplinary approach should be considered a key option for the treatment of individuals with IPF.

Surgical treatment of the pancreatic stump: preventive strategies of pancreatic fistula after pancreatoduodenectomy for cancer.

BACKGROUND: The institutions with high volume of pancreatic surgery report morbidity rate from 30% to 50% and mortality less than 5% after pancreaticoduodenectomy (PD). At the present, the most significant cause of morbidity and mortality is pancreatic fistula (PF). AIM: The purpose of the study is to identify the most important clinical factors which may predict PF development and eventually suggest alternative approaches to the pancreatic stump management. PATIENTS AND METHODS: A retrospective analysis of a clinical data base of a tertiary care Hospital was performed. From 2002 to 2012 a single Surgeon prospectively performed 150 pancreaticoduodenectomies for cancer. Four different techniques were used: end to end pancreaticojejunostomy, end to side pancreaticojejunostomy, pancreatic duct occlusion and duct to mucosa anastomosis. The intraoperative gland texture was classified as soft, firm and hard. The duct size was preoperatively (CT scan) and intraoperatively recorded and classified: < 3 mm small, 3-6 mm medium, > 6 mm large. The histopathological characteristic of the gland fibrosis was graduate as low 1, moderate 2, high 3. CONCLUSION: Relationships between pre and intraoperative duct size measurement, pancreatic texture and pancreatic fibrosis grading were highly significant. Small duct and soft pancreas with low grade fibrosis are the most important risk factors for pancreatic fistula development. The proper selection of pancreatic stump management or the decision to refer the high risk patients to high volume Center can be suggested by the elevated correspondence of pre and intraoperative duct diameter with the related pancreatic fibrosis grade and gland consistency. Preoperative assessment of the pancreatic duct makes possible to predict the risk of pancreatic fistula.

Can herniation pit of the femoral neck mimic an acute appendicitis? A case report.

Although in most cases the diagnosis of acute appendicitis is straightforward, not all patients experience typical symptoms and other conditions may mimic appendicitis. In fact, 15-25% of appendectomies involve the removal of a normal appendix. To date, there is no literature evidence that herniation pit (HP) may mimic acute appendicitis. We report a case of a 30 year old woman admitted to the Emergency Department for severe, acute pain developing a few hours earlier in the lower right fossa, with irradiaton to the right thigh. She did not present any fever, nausea or vomiting, Blumberg's sign was absent but the psoas sign and obturator sign were both positive. WBC count was 16,000/mm3 and the Alvarado score was 4. Biochemistry profile was normal. US was unclear and transvaginal ultrasound did not show any gynecological disease. CT scan showed only an herniation pit of the right femoral neck. The patient was admitted to an orthopedic ward and treated with anti-inflammatory therapy. She was discharged after 2 days without any pain and in good conditions. Our case demonstrates that herniation pits of the right femoral neck should be considered a potential cause of right lower abdominal pain mimicking acute appendicitis, particularly if the psoas sign and obturator sign are positive and the patient is physically active.

Incidental gallbladder carcinoma: our experience.

Aim. Gallbladder carcinoma is an uncommon cancer with a poor prognosis. In the era of laparoscopic cholecistectomy for treatment of benign diseases incidental gallbladder carcinoma has dramatically increased and now constitutes the major way patients present with gallbladder cancer and allows to detect cancer at early stages with a better prognosis. In this single-center study we report our experience with gallbladder carcinoma incidentally diagnosed during or after laparoscopic colecistectomy performed for cholelithiasis. Methods. From January 2003 to December 2011 a total of 1193 patients underwent cholecistectomy at General Surgical Unit III of University of Bari. The patients were 458 males and 735 females, mean age was 52 years (range 19-91). In 6 of 1188 patients adenocarcinoma was present in the pathologic specimens (0,5%). Results. Of 1188 patients in whom laparoscopic cholecistectomy was attempted adenocarcinoma was diagnosed histopathologically in 6 cases (0,5%). There was no suspicion of malignancy to any of them. Intraoperatively, gallbladder wall appeared abnormal in one patients and frozen section analysis revealed adenocarcinoma. In the remaining 5 cases routine histopathological studies revealed the diagnosis of gallbladder carcinoma. One patient had T1 tumor, two had T2 and three had T3 tumor. Conclusions. In the present study the rate of incidental gallbladder carcinoma was 0,5%, according to the published English language literature. The risk factors widely related to the gallbladder cancer are advanced age and gallstones disease. The therapeutic approach to gallbladder cancer was applied according to the stage of tumor, but in our study this was possible only in two patients with T2 and T3 tumor since high risk and important comorbidities were the main causes for the refusal of 3 patient out of 5. Only the T1 patient underwent simple cholecystectomy. Similar to other reports in this single-center study the diagnosis of incidental gallbladder carcinoma was found to be of 0,5%, thus the diagnosis of gallbladder stones is an indication to the cholecystectomy.

Colorectal retained foreign bodies per anum introduced. Three years retrospective study at Emergency Surgery Unit.

Colorectal foreign bodies per annum introduced are not exceptional. They can be classified as high-lying or low-lying, depending on their location relative to the recto-sigmoid junction. High-lying rectal foreign bodies sometimes require surgery; low-lying ones are often palpable by digital examination and can removed at bedside. No reliable data exist regarding the frequency of inserted rectal foreign bodies and the literature is largely anecdotal. We review our experience on patients almost all males and heterosexual with retained colorectal foreign bodies and their outcome in Surgical Emergency Unit of a Southern Italy University hospital.

[Overexpression of laminine-5( LN-5) in peritoneal lavage of colorectal cancer patients preliminary results]. / Overexpression della laminina-5 (LN-5) nel lavaggio peritoneale di pazienti con carcinomi del grosso intestino. Risultati preliminari.

Recent studies show that interaction between LN (heterotrimeric protein formed by a3/b3/g2 chains) and cancer cells plays an important role in tumor invasion, also in colorectal cancer. The overall survival was significantly worse in patients with free peritoneal cancer cells(FPTCs): detection of FPTCs after curative surgery is a challenge, because could improve staging and prognosis. Peritoneal citology is the current standard procedure with very low sensivity. We aimed to study the expression of LN5 in the peritoneal lavage of colorectal cancer pts and in controls with semiquantitative reverse trancriptase-polymerase chain reaction (RT-PCR). LN-5 overexpression was evaluated observing PCR- products intensity at electrophoresis: high intensity is correlated to overexpression. Pre and post-operative peritoneal lavages of 30 pts with colorectal cancer (13M;17F), with median age of 69 (58-84), and of 10 controls, were analyzed by conventional cytology and a semiquantitative RT-PCR. No cancer pts showed pre/postoperative negative cytology and did not express LN-5. In cancer pts. cytology was positive in 2 pts in pre/postoperative lavage. LN-5 overexpression was observed in 56,6% preoperatively and in 76,6% postoperatively. LN-5 g 2 chain was most frequent chain. Our study suggests a relationship between LN-5 and FPTCs, as shown by the low expression of lamimine in controls. LN-5 could be a useful marker to identify a subgroup of early-stage patients at increased risk of recurrence; moreover, mortality seems to correlated to LAMB3 chain. The diagnostic accuracy could be improved by using a quantitative RT-PCR or western-blot and detecting serum laminine. Finally, to validate these findings a larger number of pts with follow-up study is required.

Percutaneous management of complications of tuberculous spondylodiscitis: short- to medium-term results.

PURPOSE: Psoas abscesses are the most frequent complication of tuberculosis with skeletal involvement. The aim of this paper is to report our experience with the systematic application of percutaneous drainage to tuberculous psoas abscesses. MATERIALS AND METHODS: Between January 1997 and December 2005, 23 patients (14 men and nine women; age range 21-48 years), after a previous study with computed tomography (CT) and/or magnetic resonance (MR) imaging, underwent percutaneous drainage of a tuberculous fluid collection in the psoas muscles. Follow-up consisted of monthly clinical and laboratory assessment, and plain chest radiography and spinal CT every 6-12 months. RESULTS: Spondylodiscitis involved the thoracolumbar spine. Fluid collections were bilateral in 14 cases and communicating in ten of these. Maximum transverse diameter was 7 cm, whereas longitudinal diameter was 14 cm. Placement of the drainage catheter was successful in all cases, and the catheter was left in place for 5-36 (mean 18.4) days. Symptom regression occurred immediately after drainage of the fluid collection. The drainage procedure was curative in 100% of cases. Dislodgement of the drainage catheter occurred in two cases as a result of excessive traction during dressing removal. CONCLUSIONS: A serious complication of bone tuberculosis, psoas abscesses, can be effectively treated by percutaneous drainage, leading to immediate pain resolution. The drainage catheter requires daily monitoring to identify when it can be safely removed without risk of recurrence.

Amebic liver abscess: report of three cases.

Amebic abscess is a common manifestation of extraintestinal amebiasis and it is associated with relatively high morbidity and mortality. We present three cases seen in Bari, Southern Italy, one of which was autochthonous and the other two were not. Diagnosis was performed by elevated antibody titre for E. histolytica through immunofluorescence assay and positive antigen determination by ELISA in stools and in abscess aspirate. Fever often accompanied by chills, abdominal pain, weight loss and hepatomegaly were present. Laboratory findings also revealed leukocytosis with neutrophilia. Pleural effusion was observed in two patients. In all our patients multiple abscesses were observed. All the patients were treated with metronidazole and two of them also underwent the aspiration of the amoebic abscess. In all of them there was improvement of the clinical picture, as demonstrated by computerized tomography.

Lumbar sympathectomy under CT guidance: therapeutic option in critical limb ischaemia.

PURPOSE: Lumbar sympathectomy is a complementary therapeutic option for patients with severe peripheral vascular occlusive disease presenting rest pain or gangrene and not eligible for surgical revascularisation. Traditional surgical sympathectomy was widely used in the past. However, due to its invasive character, it has increasingly been replaced by percutaneous techniques and, in some recent cases, by laparoscopic procedures. Percutaneous lumbar sympathectomy is a safe, cost-effective and widely available treatment option. We report our experience on 19 patients subjected to percutaneous sympathectomy under CT guidance. MATERIALS AND METHODS: Between 1998 and 2000, 19 patients underwent percutaneous sympathectomy under CT guidance. All patients had severe vascular disease of the lower extremities (Fontaine stage IV), with rest pain and gangrene. They were not eligible for surgical revascularisation. Phenol was injected at the level of L2 and L4 using two 22 G needles (15 cm long). Signs of interrupted sympathetic activity usually occur 2'-15' after the procedure with warmth and flushing and dryness of the lower extremities. RESULTS: Percutaneous sympathectomy under CT guidance is a simple, safe and well-tolerated procedure with a low rate of complications. Of the 19 patients, 9 (47.3%) showed clinical improvement, whereas 5 experienced a worsening of ischaemia in the months immediately following the procedure. DISCUSSION: Results suggest that percutaneous lumbar sympathectomy causes a sympathetic blockade in patients with advanced vascular disease of the limbs. CT guidance ensures a high level of precision in drug dosing, thus lowering the risk of complications. Although the results are demoralizing. the impossibility of achieving surgical revascularisation in advanced peripheral arteriosclerosis enhances the role of CT-guided percutaneous sympathectomy in relieving rest pain and healing ulcers in order to postpone the amputation.

[Splenic trauma: splenectomy in every case?]. / I traumi splenici: splenectomia in ogni caso?

The authors report their experience in the conservative treatment of splenic traumas observed in the period 1987-1997. They point out the difference in the incidence of splenectomy in comparison with conservative treatment (p < 0.001) and nonoperative management (p < 0.05) in the two periods examined (1987-92 and 1993-97). They stress the manifold functions of the spleen and his role in the immunitary defense above all in pediatric age, and emphasize, on the base of their experience, the conservative treatment of traumatic splenic injuries in patient carefully selected. This curative strategy is supported by the notable contribution offered by sophisticated methods of radiological imaging (echography, CT, angiography) and by the commercialization of substances at high stick capacity (Tissucol). The lack of complications at short and middle term (reoperation for restart of the hemorrhage and ischemic necrosis after ligature of the splenic artery) induces the authors to consider the conservative treatment of the splenic traumas, in the cases in which it is pursuable, an ideal therapeutic solution.

[The diagnostic and therapeutic strategy in the treatment of foreign bodies of the upper digestive tract: a report of a clinical case and a review of the literature]. / Strategia diagnostica e terapeutica nel trattamento di corpi estranei dell'apparato digerente superiore: descrizione di un caso clinico e revisione della letteratura.

The author reports a rare case of foreign bodies ingestion treated surgically. The diagnosis and the type of treatment that must be adopted are defined. The literature is reviewed and the described data compared with the observed case.

[Obstructive jaundice caused by hydatid cyst rupture in main bile duct]. / Ittero ostruttivo da rottura di cisti idatidea nella via biliare principale.

Hydatid hepatic cyst rupture into bile duct is a complication of hydatid disease. The rupture is more frequent in right or left epatic duct and occasionally in common bile duct (7-9%). A 50-year old man came to emergency room owing to jaundice, fever and abdominal pain. TC show an hydatid cyst with daughter's cyst of left liver and dilatation of biliary tree. Laboratory data of significance included an increased of liver function tests (Bilirubin, Alkaline ph., SGOT, SGPT), VES and leukocytosis. The patients was surgically treated, by total pericystectomy, colecystectomy and coledocotomy with lavage o common bile duct; finally we placed one Kehr drainage and two abdominal drainage. After 15 days of postoperative hospitalization patient was discharged. The best treatment of hydatid cyst is total pericystectomy (when possible). An alternative surgical treatment is possible for the presence of communication with biliary tree. ERCP is very important for a correct diagnosis and for a complete surgical treatment.

[Diverticula of the small intestine: the authors' own experience]. / I diverticoli dell'intestino tenue: contributo d'esperienza.

The Authors report the experience acquired in the management of small bowel diverticula at the Emergency Surgical Department of the University of Bari, from 1987 to 1993. After a brief illustration of the few cases observed, the Authors discuss the problems of this rare pathology, which as all types of bowel diverticula, is diagnosed with difficulty. In fact, only in case of complications, with a specific check-up, the lesions may be discovered. Although rarely, emergency surgery may be needed when complications such as bleeding or occlusion occur. Usually the treatment of minor complications (dyspepsia, gripes, steatorrhoea, constipation and diarrhoea) consists of dietetic indications and symptomatic drugs.

[Intrahepatic cholangiojejunostomy on the third segment in non-operable neoplasms of the hepatic hilum]. / La colangiodigiunostomia intraepatica al III segmento nelle neoplasie inoperabili dell'ilo epatico.

The authors report their experience in 19 cases of primitive or secondary tumor of the hilus of the liver which couldn't benefit from radical operation. Palliative treatments--to resolve the jaundice (which is often the only responsible for a short-term exitus)--include surgical (intrahepatic bilio-digestive derivations) and non surgical procedures (PTDB, percutaneous transtumoral intubation). Considering the ephemeral results of the latter, the Authors take peripheral derivative operations into account and particularly the Soupault and Couinaud technique (intrahepatic colangiojejunostomy) performed in 7 patients with satisfying results. It is an easy and quick technique--because of constant anatomical situation of the left intrahepatic biliary distribution and of the superficial location of the duct of the III segment--which allows a lasting biliary decompression with a good residual life.